Andreas M. Sesterhenn

A meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative neck.

There is still no consensus on the optimal treatment of the neck in oral cavity cancer patients with clinical N0 neck. The aim of this study was to assess a possible benefit of elective neck dissection in oral cancers with clinical N0 neck. A comprehensive search and systematic review of electronic databases was carried out for randomized trials comparing elective neck dissection to therapeutic neck dissection (observation) in oral cancer patients with clinical N0 neck. A meta-analysis of the studies which met our defined selection criteria was performed using disease-specific death as the primary outcome, and the relative risk (RR) of disease-specific death was calculated for each of the identified studies. Both fixed-effects (Mantel-Haenszel method) and random-effects models were applied to obtain a combined RR estimate, although between-study heterogeneity was not found to be significant as indicated by an I(2) of 8.5% (p=0.350). Four studies with a total of 283 patients met our inclusion criteria. The results of the meta-analysis showed that elective neck dissection reduced the risk of disease-specific death (fixed-effects model RR=0.57, 95% CI 0.36-0.89, p=0.014; random-effects model RR=0.59, 95% CI 0.37-0.96, p=0.034) compared to observation. This reduction in disease-specific death rate supports the need to perform elective neck dissection in oral cancers with clinical N0 neck.

A devastating outcome after adenoidectomy and tonsillectomy: Ideas for improved prevention and management

Objective: To develop strategies that may assist the surgeon to prevent and manage severe bleeding complications after adenoidectomy and tonsillectomy. Study Design: Retrospective. Subjects and Methods: Expert reports for malpractice lawsuits or professional boards were reviewed. The review was restricted to “deaths” and “permanent generalized neurological deficiencies.” Results: Forty-three cases matched our search criteria, including 32 deaths. Adenoidectomy cases (2) were associated with immediate bleeding because of direct vascular injury resulting in one death. Tonsillectomy cases were associated with delayed and repeated episodes of bleeding resulting in 31 deaths, including 19 children. Autopsy verified predominantly aspiration and vascular injuries. An apallic syndrome prevailed in surviving patients. Conclusion: Careful inspection of the nasopharynx immediately before adenoidectomy and curettage in a piecemeal fashion under visual control is helpful to prevent direct injury to aberrant arteries. Tonsillectomy cases are associated with delayed and episodic bleeding with spontaneous cessation and young age. Inpatient observation should be strongly considered in cases with repeated bleeding episodes to provide immediate treatment. The follow-up should be focused on disturbed wound healing. Outcome appears to be dependant on adequate airway management. Rigid instruments and tracheotomy in case of intubation failure are highly recommended to facilitate airway protection and ventilation.

Microcystic Lymphatic Malformations of the Tongue Diagnosis, Classification, and Treatment

OBJECTIVE To describe a classification of microcystic lymphatic malformations of the tongue and to investigate different treatment methods. DESIGN Retrospective review of patients treated for microcystic lymphatic malformations of the tongue. Lymphatic malformations were classified into the following 4 groups according to their extent: isolated superficial microcystic lymphatic malformations of the tongue (stage I); isolated lymphatic malformations of the tongue with muscle involvement (stage II; stage IIA, involving a part of the tongue; stage IIB, involving the entire tongue); microcystic lymphatic malformations of the tongue and the floor of mouth (stage III); and extensive microcystic lymphatic malformations involving the tongue, floor of mouth, and further cervical structures (stage IV). PATIENTS Twenty patients with microcystic lymphatic malformation of the tongue. MAIN OUTCOME MEASURES Medical records were reviewed for demographic data and extent and treatment of the lymphatic malformations. RESULTS Three patients had stage I disease; 5 patients, stage II; 3 patients, stage III; and 9 patients, stage IV. In 6 patients, the lymphatic malformations could be completely removed by carbon dioxide laser surgery; the remaining 13 patients had persistent disease. CONCLUSIONS The initial stage seems to predict outcome. Carbon dioxide laser therapy provides good results primarily in stages I and IIA lymphatic malformations. In advanced lymphatic malformations (stages IIB, III, and IV), an interdisciplinary approach is necessary, because complete surgical excision is often impossible owing to the diffuse growth behavior, and therefore recurrence and persistence are common.

Analysis of pneumatization and neurovascular structures of the sphenoid sinus using cone-beam tomography (CBT).

Background The sphenoid sinus is a frequent target of paranasal sinus surgery. Because of the high risk of injuring the surrounding structures (e.g. internal carotid artery, optical nerve) a preoperative imaging is absolutely necessary. Purpose To analyze the possibilities of cone-beam computed tomography (CBCT), which is especially quite a new technique in ENT, in the evaluation of the sphenoid sinus, its surrounding structures, and the corresponding anatomical variations. Material and Methods This was a retrospective, single-centre study of 580 patients (1160 sides = cases). The Accu-I-Tomo-F17 was used. Pneumatization of sphenoid sinus, course of internal artery, course of optical nerve, and dehiscence of the bony canals were evaluated. Results In the case of pneumatization a type I (completely missing or minimal sphenoid sinus) was found in two patients (0.3%), type II (posterior wall of sphenoid sinus is in front of the anterior wall of the sella) in 38 patients (6.6%), type III (posterior wall is between anterior and posterior wall of sella) in 332 patients (57,2%), type IVa (posterior wall is behind the posterior wall of sella without air dorsal the sella) in 104 patients (17.9%), and type IVb (similar to type IVa but with air dorsal the sella) in 104 patients (17.9%). In 1025 cases (89.5%) a smooth course of the internal carotid artery was found whereas a free course could be detected in 120 cases (10.5%). Defects of the bony canal of the optical nerve were found in 16.7% and of the internal carotid artery in 2.7% of the cases. The optical nerve showed a free course through the sphenoid in 151 cases (13.7%) and a smooth course in 1007 cases (87.0%). Conclusion CBCT could evaluate all relevant anatomic structures and answer the questions of different anatomical variants. A modified classification of the pneumatization of the sphenoid sinus could be described. Frequencies of anatomical variations are in accordance with the current literature of CT research.

LASER SURGICAL TREATMENT OF LARYNGEAL PARAGANGLIOMA

Paragangliomas are rare benign neoplasms arising from the neural crest-derived paraganglia of the autonomic nervous system. In the larynx three different localizations of paraganglia are known. Most laryngeal paragangliomas arise from the supraglottic paraganglia. A review of the literature shows that the treatment of choice for laryngeal paragangliomas is surgical excision. Since the implementation of CO(2) laser surgery into laryngology in 1972, no reports of endoscopic laser surgical excisions of laryngeal paragangliomas have been published so far. We present the case of a 66-year-old female patient who suffered from a large (4 x 4 x 3 cm) left supraglottic paraganglioma. The tumour was completely excised utilizing the CO(2) laser. Histopathology and immunohistochemistry of the tissue presented the typical findings of a laryngeal paraganglioma. The pre- and post-operative management as well as the treatment strategies are discussed. To our knowledge the present case demonstrates for the first time a complete transoral CO(2) laser surgical resection of an advanced laryngeal paraganglioma.

Cutaneous manifestation of myiasis in malignant wounds of the head and neck

UNLABELLED Parasitic infestation of the body by dipterous larvae belongs to the most undesirable events in cancer patients with malignant cutaneous wounds. Human myiasis is rare in developed countries of the northern hemisphere but occurs more often in tropical and subtropical regions. Advanced age, poor hygiene, bad housing conditions, vascular disease and diabetes seem to be predisposing factors for myiasis. We report a case of myiasis in an extensive skin metastasis resulting from a primary cancer located in the oropharynx. In the literature there are few reports on myiasis in malignant wounds resulting from malignancies of the head and neck area. Furthermore, guidelines or recommendations for standard treatment options are not available. Therefore a review of the literature with a focus on therapeutical aspects was performed. CONCLUSION At present the treatment of choice for human myiasis in malignant cutaneous wounds comprises mechanical removal of maggots and, if possible, surgical excision of the lesion. Most important in the treatment of malignant wounds is a thorough rinsing procedure with antiseptic- and/or antibiotic solutions before consistent dressing changes on a daily basis. Here, a complete covering of the wound is indispensable, especially in the summer months.

Digital volume tomography (DVT) as a diagnostic modality of the anterior skull base.

Conclusion. Because of high resolution and the relatively lower costs in comparison with modern helical CT scanners, digital volume tomography (DVT) can be recommended in the diagnosis of the nasal cavity and paranasal sinuses. Objectives. DVT is an advancement of panoramic tomography and is based on the principles of rotational tomography. It enables high resolution visualization of osseous structures. The slices can be displayed in three orthogonal planes that can be changed in angle arbitrarily. Data volumes of up to 12×17 cm can be examined with a new generation of the DVT. The aim of this study was to point out the potential of DVT in the anterior skull base. Subjects and methods. DVT scans with a cylindrical size of 10 cm in diameter and 10 cm in height were performed in 23 patients. The identification of surgical key landmarks (uncinate process, middle turbinate, ethmoidal bulla, agger nasi cells, Haller cells, frontal recess, anterior ethmoidal artery in its relationship to the skull base, the cribiform plate of the sphenoidal sinus in relation to the optic nerve, and the internal carotid artery) was evaluated. Results. Display of the essential surgical key landmarks was possible in all patients

Head and neck cancer in the elderly: A cohort study in 40 patients

Introduction In the industrialized nations of the Western hemisphere the age group beyond 75 years will grow steadily, requiring special attention by medical professionals in the future. With regard to these expectations 40 patients, beyond the age of 75 and who were first diagnosed to suffer from squamous cell carcinoma of the upper aerodigestive tract, were analysed. Material and methods Forty patients diagnosed and treated between 1998 and 2003 for head and neck squamous cell carcinoma (HNSCC) were analysed. Results Laryngeal carcinoma was noted in 80% of the patients. All types of treatment were tolerated well. Patient compliance was generally good and the rate of complications was low. Conclusion The results of the present study show that HNSCC in elderly patients should be treated with curative intention. Age itself should never be a sole factor in deciding which curative therapy should be undertaken. Exceptions could be made in patients with severe general comorbidity.

Acute haemorrhage in patients with advanced head and neck cancer: value of endovascular therapy as palliative treatment option.

AIMS Acute or subacute haemorrhage is one of the most frightening complications in patients suffering from advanced head and neck cancer. Few articles report experience with superselective endovascular therapy for this purpose. Is endovascular therapy underestimated in the field of palliative head and neck cancer therapy? This study set out to investigate this question. PATIENTS AND METHODS A review was undertaken of the clinical courses of seven patients (six men, one woman) suffering from incurable, advanced head and neck cancer (four pharyngeal, two laryngeal, one neck) and treated with superselective endovascular strategies as an emergency procedure for acute bleeding. RESULTS All patients were successfully treated without evidence of neurological complication. Patients reached a median survival of 20 weeks (range eight-168 weeks). Following endovascular treatment all patients were discharged from the hospital within several days. Three patients survived almost free of symptoms for several weeks and were able to stay at home with their families until their death. CONCLUSION We conclude that in the field of palliative care, superselective endovascular therapy deserves to be considered alongside standard treatment options for the management of acute haemorrhage from advanced head and neck cancer.

From the expert’s office: localized neural lesions following tonsillectomy

Due to various reasons, localized neural lesions following tonsillectomy are presumably an under-reported complication in the literature. This study was undertaken to compile our experiences including a literature review to disseminate useful insights in the etiology and prognosis of this rare entity. A retrospective chart review of expert reports written by at least one of the authors for malpractice claims in relation to tonsillectomy was undertaken. Additionally, a retrospective analysis of 648 patient documents that had undergone tonsillectomy in 2001 at our institution and a comprehensive literature review were performed. The research was restricted to the item “localized neural lesion”. Seven cases from the expert’s offices, one of our patients who had undergone tonsillectomy at our institution and 122 cases from the literature matched our search criteria. Including our own cases, the glossopharyngeal nerve was affected in 82 patients. Other lesions encompassed injury of the hypoglossal nerve as solitary (15) or combined (5) lesion, recurrent nerve paralysis with (2) or without additional nerve lesions (7), facial nerve paralysis (10) in combination with other nerve lesions (1), and a lingual nerve deficiency as solitary (4) or combined lesion (9). A single report existed for lesion of the phrenic nerve. There were five reported cases with blindness and nine cases with Horner’s syndrome. Albeit rare, localized neural lesions may occur as a troublesome complication following tonsillectomy and/or means to achieve hemostasis. Some of these cases may not result from the dissection itself but injection procedures. Surgical dissection should include careful mouth gag insertion and meticulous dissection to minimize the risk of localized neural complications. A long-term follow-up is recommended for patients with dysgeusia related to glossopharyngeal nerve injury and patients with recurrent nerve dysfunction. Other lesions are much less likely to resolve in the long-term. Localized neural lesions should adequately be included in the informed consent for tonsillectomy as well as for surgical treatment of post-tonsillectomy hemorrhage.